VASCULAR SOLUTIONS - Vascular and Endovascular Surgeons Treating Peripheral Vascular Disease in Cleveland, Ohio

Vascular Solutions

patients with less than 50 percent stenosis. Furthermore, the benefit of carotid endarterectomy in symptomatic patients with stenosis of 70 percent or greater has been established in two additional major studies. Advanced age by itself should not be considered a contraindication for surgery in properly selected patients with symptomatic high-grade carotid artery stenosis.

Asymptomatic carotid disease is a less straight forward than the symptomatic issue. In the Asymptomatic Carotid Atherosclerosis Study (ACAS), carotid endarterectomy was beneficial in patients who had asymptomatic carotid artery stenosis of 60 percent or greater and whose general health made them good candidates for elective surgery, provided that the arteriographic and surgical complication rates were low by a given surgeon. The recommendation is that a surgeon should have a less than 3% combined stroke and death rate. The benefit of carotid endarectomy in this group of patients was less powerful than the symptomatic trials. In general Vascular Solutions suggests an intervention on a patient whos carotid disease exceeds 75%. When stenosis is more than 75 percent, the combined rate for TIA and stroke is 10.5 percent per year, with most events occurring ipsilateral to the stenosed carotid artery (Stroke 1991;22:1485-90). Age is not a factor, but in asymptomatic carotid disease, survival is a factor. Because an intervention prevents a potential future event, its benefit is derived over time. If a patient is not going to survive more than a couple of years, then the risk reduction of an intervention may not be seen.

Asymptomatic:

The overall benefit of carotid endarterectomy strongly depends on surgical risk. Appropriate patient selection and preoperative control of risk factors remain key issues for the family physician to consider. Medical strategies may include the use of platelet antiaggregants, risk factor modification and preoperative evaluation for coronary artery disease. Age, however, is not a factor.

Because variability in outcome after carotid endarterectomy is well recognized, guidelines for the surgical risk of this procedure have been established. Mortality and morbidity rates associated with carotid endarterectomy are significantly lower in asymptomatic patients than in symptomatic patients. The acceptable level of surgical risk (i.e., the combined risk of stroke and death) varies with the indication for carotid artery surgery. Acceptable guidelines for operative risk are 3 percent for asymptomatic patients, 5 percent for patients with TIA, 7 percent for patients with stroke and 10 percent for patients with recurrent stenosis. Vascular Solutions is pleased that all of the vascular specialists in our group have far better results than these guideline risks. We would be pleased to present our most current stastistics during a consultation.

Summary of asymptomatic vs symptomatic

All of the information thus far has been based on long term studies of an operative method for removing plaque from the carotid artery. Carotid endarectomies have been preformed since the early 1950's with excellent results. Recently a new method using endovascular techniques has emerged called carotid stenting. Earlier this summer Guidant was the first company to have a FDA approved stent for this application. Cordis is expected to have a FDA approved stent by Jan 2005 and Boston Scientific later in 2005. The links below will take you though the option of the traditional carotid endarectomy and the newer carotid stenting procedure. Which method is best for you can only be determined by a treating physician familiar with both techniques. Vascular Solutions would be pleased to provide you a consultation to determine which is appropriate for you.

Options for treatment:

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